Version May 2024
INTRODUCTION — Although lung cancer remains the leading cause of cancer mortality in individuals in the United States, advances in detection and treatment have increased the likelihood of long-term survival. In the United States, lung cancer is estimated to be diagnosed in approximately 240,000 people annually and causes almost 130,000 deaths [1]. Similarly, in the European Union in 2012, there were approximately 310,000 new cases and 265,000 deaths due to lung cancer [2]. Currently, there are an estimated 384,000 survivors of lung cancer in the United States, accounting for 4 percent of the adult cancer survivor population, and this number is increasing [3], attributable to advances in early detection (low-dose computed tomography scanning) and treatment. (See "Screening for lung cancer".)
The issues facing cancer survivors and the approach to their management are discussed here. Overviews of lung cancer risk factors and initial evaluation and treatment are presented separately. (See "Clinical manifestations of lung cancer" and "Overview of the initial treatment and prognosis of lung cancer".)
DEFINITION OF A LUNG CANCER SURVIVOR — The most widely accepted definition of a "cancer survivor" is a person who has been diagnosed with cancer, starting the day of their diagnosis until the end of life [3]. Within this broad definition, a long-term cancer survivor has been defined as a person who is living five years after diagnosis with or without disease [4,5].
For purposes of this discussion, lung cancer survivors are characterized as individuals who have been diagnosed with lung cancer and have completed all of their treatment for lung cancer. This topic will discuss the approach to lung cancer survivors and is focused on patients seen in a coordinated care setting between their primary care and oncology providers as well as those exclusively cared for by their primary care providers following treatment for lung cancer. These patients predominantly have had non-small cell lung cancer, since prolonged disease-free survival of patients with small cell lung cancer is much less common.
EPIDEMIOLOGY AND STAGING — The term "lung cancer" refers to malignancies that originate in the airways or pulmonary parenchyma. Approximately 80 percent of all lung cancers are classified as non-small cell lung cancer (NSCLC), and most of the remainder are small cell lung cancer (SCLC). This distinction is required for proper staging, treatment, and prognosis. Smoking tobacco products is the primary cause of lung cancer; approximately 85 percent of lung cancer cases occur in current or former smokers. (See "Cigarette smoking and other possible risk factors for lung cancer" and "Pathology of lung malignancies".)
For patients with NSCLC, the Tumor, Node, Metastasis (TNM) staging system is used (table 1). Although the TNM system can also be applied to SCLC, a simplified version that separates these patients into those with limited versus extensive disease is more widely used. The details of the staging system and the initial approach to establishing the diagnosis and extent of disease are discussed in detail separately.
●(See "Overview of the initial treatment and prognosis of lung cancer".)
●(See "Tumor, node, metastasis (TNM) staging system for lung cancer".)
●(See "Pathobiology and staging of small cell carcinoma of the lung", section on 'Staging'.)
ONCOLOGIC MANAGEMENT
Initial treatment — The initial management of a patient with lung cancer depends heavily upon whether the tumor is a small cell (SCLC) or non-small cell lung cancer (NSCLC). For patients with NSCLC, management is based upon the extent of disease, as well as the patient's age, treatment preferences, and comorbid conditions. (See "Overview of the initial treatment and prognosis of lung cancer", section on 'NSCLC'.)
●For patients who present with localized disease and without evidence of mediastinal lymph node involvement (stage I and stage II (table 1)), surgical resection offers the best opportunity for long-term survival and cure in patients with resectable NSCLC. Local ablative therapy, particularly stereotactic radiation therapy (RT) techniques, may be an appropriate alternative for patients who are not surgical candidates. Postoperative adjuvant chemotherapy may improve overall survival in patients at increased risk of disease recurrence. (See "Management of stage I and stage II non-small cell lung cancer".)
●For patients with mediastinal lymph node involvement (stage III disease) at presentation, a combined-modality approach using chemotherapy and RT with or without surgery is generally preferred. (See "Management of stage III non-small cell lung cancer".)
●Patients with distant metastases (stage IV disease) at presentation or who subsequently have a recurrence with disseminated disease following definitive therapy are generally treated with systemic therapy. This may include chemotherapy, molecularly targeted therapy, or immunotherapy depending upon the characteristics of the individual patient's tumor. In appropriately selected patients, these approaches may prolong survival or decrease disease symptoms without sacrificing quality of life. RT and surgery may also be useful for symptom palliation in some patients. (See "Overview of the initial treatment of advanced non-small cell lung cancer".)
SCLC is a disseminated disease in most patients, even at presentation, and prolonged survival is achieved in only a small minority of patients. Thus, systemic chemotherapy is an integral part of the initial treatment; management may also include RT to the thorax or to the brain, depending upon the initial extent of disease. (See "Overview of the initial treatment and prognosis of lung cancer", section on 'SCLC'.)
SURVEILLANCE AFTER TREATMENT — Close surveillance for survivors of lung cancer who have received definitive therapy has been endorsed by numerous society guidelines [6-9] because they remain at risk for recurrence of their disease and for the development of second primary lung cancers [4,5,10].
Rationale — Although there is no clear evidence demonstrating a survival benefit with surveillance after treatment for lung cancer, the rationale is to detect recurrent disease, a second primary lung cancer, or other smoking-related malignancy early enough so that an intervention can increase survival, offer curative retreatment, and/or improve quality of life [11].
Even with completely resected early-stage lung cancer, recurrence rates are high. (See "Overview of the initial treatment and prognosis of lung cancer", section on 'Prognosis of NSCLC' and "Overview of the initial treatment and prognosis of lung cancer", section on 'Prognosis'.)
Unfortunately, the majority of recurrences present at distant sites and have a poor prognosis, but a small proportion of patients do present with localized and potentially salvageable relapses. The majority of locoregional and distant recurrences occur within the first two years [10,12].
Approach — The approach to post-therapy surveillance, the efficacy of surveillance, and the management of recurrences are discussed in detail separately. (See "Management of stage I and stage II non-small cell lung cancer", section on 'Post-therapy surveillance' and "Overview of the initial treatment of advanced non-small cell lung cancer".)
The following approach draws upon recommendations from multiple guideline-setting groups [6-9].
●A history, physical examination, and chest computed tomography (CT) including the adrenals, preferably with intravenous contrast, are indicated every six months for at least the first two years to evaluate for recurrence, and annually thereafter to surveil for recurrence and for new cancers [9]; some guidelines have even recommended every-six-month follow-up for up to four years [6]. Fluorodeoxyglucose positron emission tomography (PET)/CT imaging should not be used for surveillance, and low-dose CT may be used for the annual assessment after year 2 [9].
Patients who have had lung cancer are also at increased risk of a second primary, particularly of the lung, and may benefit from early detection of a second primary as well as from detection of a local recurrence. Thus, continued follow-up beyond five years with low-dose CT screening is reasonable in patients who have no evidence of disease, since these individuals are at risk for a second primary lung cancer as well as for recurrence. (See "Screening for lung cancer" and "Multiple primary lung cancers".)
The risk of a second primary lung cancer appears to be greater in smokers [13], although the data are conflicting. In a study of 2151 stage I adenocarcinomas, a second primary lung cancer developed in 10 percent of nonsmokers and 8 percent of smokers. There was no difference in the cumulative incidence rate of a second primary lung cancer between smokers and nonsmokers [14]. The vast majority of second primary lung cancers were detected at a curable stage. In a smaller study examining 569 patients with stage I non-small cell lung cancer (NSCLC), a second primary lung cancer developed in 9 percent of patients, although no second primaries occurred in the 44 patients who were never-smokers [15].
●Patients are also at risk for the development of second smoking-related malignancies at other sites. These cancers may arise at a wide range of primary sites [16], and the primary care provider should have a low threshold to obtain diagnostic imaging for unexplained symptoms. Survivors of stage I lung cancers who were current smokers at the time of diagnosis have a greater than threefold risk of developing second smoking-related malignancies (eg, head and neck, bladder), underscoring the critical importance of smoking cessation in these patients [17]. (See 'Persistent tobacco use' below.)
●For patients who have undergone curative-intent treatment for stage I to III NSCLC, clinicians should not use brain magnetic resonance imaging (MRI) for routine surveillance; however, for those who have undergone curative-intent treatment for limited-stage small cell lung cancer, brain MRI every three months for the first year and every six months for the second year should be offered for surveillance for new or recurrent brain metastases [9].
●Circulating biomarkers should not be used as a surveillance strategy for detection of recurrence [9].
Although immunotherapy has had a significant impact on the treatment of advanced lung cancer, it has not affected surveillance recommendations in cancer survivors.
Potential harms of surveillance — One should also be mindful that patients undergoing routine surveillance imaging are subject to radiation exposure, the potential risks of false-positive results, and the anxiety associated with each test. However, the theoretical risk from radiation exposure, particularly from low-dose scans as has been recommended for surveillance, is generally accepted given the potential for identification of second malignancies at a curable state in this high-risk population [6,14,17,18]. Furthermore, false-positive results lead to complications in fewer than 0.4 percent of patients undergoing routine surveillance among lung cancer survivors, comparable to the rate seen among patients in the population undergoing CT screening for lung cancer [18,19]. (See "Radiation-related risks of imaging".)
COMPLICATIONS OF TREATMENT AND LATE EFFECTS — Long-term effects of treatment in lung cancer survivors revolve around complications from surgery, chemotherapy, immunotherapy, and/or radiation.
●Sequelae from surgery most commonly can include chronic pain (including post-thoracotomy pain syndrome), dyspnea, and, less frequently, the need for supplemental oxygen.
●Common long-term sequelae from chemotherapy include neuropathy and hearing loss, as well as neurocognitive changes. (See "Overview of neurologic complications of platinum-based chemotherapy".)
●Immunotherapy has been associated with a range of autoimmune-related adverse events, including dermatologic, gastrointestinal, and endocrinologic side effects. (See "Toxicities associated with immune checkpoint inhibitors".)
●Radiation can cause skin changes, radiation pneumonitis, esophagitis, and cardiovascular disease. These and other complications of treatment and late effects can result in long-term psychosocial sequelae and diminished quality of life. (See "Cardiotoxicity of radiation therapy for breast cancer and other malignancies" and "Radiation-induced lung injury".)
SYMPTOMS — Lung cancer survivors commonly report post-treatment symptoms such as pain, dyspnea, distressed mood, sleep impairment, neuropathy [20], and fatigue, which negatively impact quality of life [6-8,12,21,22]. Although some of these symptoms will gradually improve within 6 to 12 months after initial treatment, impairments in quality of life, psychological functioning [23], and physical functioning may persist for several years [6-8,12,16,24-26].
Fatigue, dyspnea, pain — Lung cancer survivors frequently report a variety of physical symptoms, including fatigue, dyspnea, pain, coughing, insomnia, impaired cognitive function, and psychological distress [27-31]. These can contribute to a sedentary lifestyle and decreased functioning ability [3,32]. Nearly 80 percent of lung cancer survivors report some difficulty with a physical symptom, and this is clinically significant in approximately 30 percent of lung cancer survivors [29,33].
●Fatigue is one of the most common postsurgical symptoms reported by lung cancer survivors (up to 90 percent in some studies) [3,4]. Fatigue is linked to depression, anxiety, chronic pain, psychological distress, dyspnea, and sleep disturbances [3,34].
●Dyspnea is also common in lung cancer survivors [35,36]. The American Thoracic Society suggests the prevalence ranges from 55 to 87 percent in all stages of lung cancer.
●Chronic pain has also been reported in approximately 50 percent of lung cancer survivors, specifically after a thoracotomy [37]. Approximately one-half of lung cancer patients report inadequate pain control, and nearly 40 percent of long-term lung cancer survivors report chronic pain symptoms [3].
●Lobectomies and bilobectomies have been associated with significant declines in sleep, mental function, sexual activity, and overall health-related quality of life, even years postresection [38].
●Patients who undergo chemotherapy tend to report symptoms leading to a decreased quality of life. Side effects associated with chemotherapy can occur in patients regardless of sex, age, or stage of cancer [4,28,39].
●Chemotherapy-induced peripheral neuropathy is a common treatment side effect and can cause severe pain and changes in heart rate and blood pressure, and in more severe cases paralysis or organ failure [40-42].
●Immunotherapy is increasingly being used as treatment for recurrent disease, and has been associated with durable remissions in a significant number of cases. Such treatment is associated with a range of immune-mediated toxicities that include dermatologic toxicities, diarrhea/colitis, hepatotoxicity, and endocrinopathies, although other sites can also be affected. (See "Initial management of advanced non-small cell lung cancer lacking a driver mutation" and "Toxicities associated with immune checkpoint inhibitors".)
●There is evidence of health disparities along racial, ethnic, and sociodemographic lines for physical health symptoms. Survivors who report African American and Hispanic race, low socioeconomic status, and low education are more likely to report worse physical health outcomes and less physical activity [43,44].
Psychological distress — Psychological distress is common. Up to 80 percent of lung cancer survivors experience psychological distress, and this rate is three times more common than observed among survivors of other types of cancers [3]. Although the causes of heightened distress in lung cancer survivorship are largely unknown, it may be associated in part with the poor prognosis and perceived stigma attached to this disease [45,46].
Psychological distress can include symptoms of generalized fear; specific fear of recurrence, sadness, worry, or uncertainty; stress, including relationship stress; poor sleep quality; lack of concentration; depression; anxiety; suicidal ideations; and survivor's guilt [47-49]. Emotional and psychological distress cause negative changes in social and cognitive functioning. Among lung cancer survivors, heightened anxiety is correlated with an increase in physical symptoms and a decrease in overall functioning [3].
Research suggests that psychosocial interventions can reduce distress in lung cancer patients, but mental health services are generally under-utilized [30]. Clinicians treating survivors of lung cancer might consider routine screening for depression (PHQ-9), anxiety (GAD), and/or psychological distress (Distress Thermometer). (See "Screening for depression in adults" and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Diagnostic criteria'.)
There is evidence of geographic and racial and ethnic disparities in mental health outcomes such as depression, anxiety, quality of life, and distress between lung cancer survivors living in rural areas as compared with survivors living in urban areas, and in racial and ethnic underrepresented groups as compared with White survivors. Lung cancer survivors in rural communities, those who are in racial and ethnic underrepresented groups, and those who have low socioeconomic status may experience poor post-treatment mental health for a variety of reasons, including limited access to mental health services, fewer socioeconomic resources, and limited access to a support network of other lung cancer survivors [50].
Stigma — Given that lung cancer is highly linked with tobacco smoking, lung cancer patients report that others tend to assume they are at fault for getting lung cancer [51]. Stigma is more strongly associated with lung cancer than other cancers. Stigma can have a negative effect on lung cancer patients' psychological well-being and has been associated with anxiety and depression. Perceived stigma can lead to social isolation and avoidance, which sometimes discourages patients from seeking medical care and psychosocial support [51,52]. There is growing recognition of the need for multilevel interventions to prevent and mitigate stigma experienced by lung cancer patients/survivors [53,54].
Cognitive impairment — More than one-half of cancer survivors report cognitive difficulties, which are believed to be the result of various treatments, and can persist for decades, significantly impacting quality of life [55]. Many cancer survivors describe subjective difficulties with attention, concentration, and short-term memory. Both surgery [56] and chemotherapy [57-59] are associated with cognitive decline in non-small cell lung cancer (NSCLC) patients. Some data suggest that chemotherapy, specifically cisplatin and doxorubicin [60], commonly used in the treatment of lung cancer patients, can contribute to cognitive deterioration [61].
Unfortunately, brain metastases are common in both NSCLC and small cell lung cancer (SCLC). In addition to the symptoms brain metastases may cause, radiation therapy may contribute to cognitive impairment. Prophylactic cranial radiation may lead to chronic neurotoxicity and impaired cognitive functioning in patients with SCLC [62]. (See "Delayed complications of cranial irradiation", section on 'Neurocognitive effects'.)
A pilot study found that 35 percent of NSCLC patients showed impaired performance in at least one cognitive domain, and that a significant number of NSCLC patients (20 percent) experienced increased depression and anxiety associated with perceived cognitive impairment [61]. However, most of their symptoms resolved after receiving psychotherapy.
Sexual dysfunction — More than 60 percent of cancer survivors report having long-term sexual dysfunction; however, fewer than 25 percent seek help [63]. Sexual concerns are prevalent in lung cancer survivors, although this is less frequent than with gynecologic or genitourinary cancers, and sexual dysfunction in female cancer patients remains underdiagnosed and undertreated [64,65]. Lung cancer survivors receive significantly less information on this topic than patients with cancers involving sexual organs, such as the prostate or ovaries [66]. (See "Overview of sexual dysfunction in male cancer survivors" and "Overview of sexual dysfunction in female cancer survivors" and "Overview of sexual dysfunction in females: Management", section on 'Cancer survivors'.)
Shortness of breath, fatigue, and emotional distress have been indicated as contributing factors for sexual functioning problems in lung cancer survivors [65,67]. Additionally, lung cancer patients report problems with sexual desire, erectile function, orgasm, frequency of sexual activity, body image, and communication about sex [67] that worsens during treatment [63] and remains problematic even after completion of lung cancer treatment [68].
ADDRESSING RISK BEHAVIORS
Persistent tobacco use — In non-small cell lung cancer (NSCLC) survivors, persistent smoking after diagnosis is associated with poor outcomes [3,69-71], including treatment complications, treatment-related toxicity, decreased overall quality of life, and decreased adherence to treatment. Along with advanced tumor stage, current smoking is a poor prognostic factor for lung cancer patients [72].
Patients who continue to smoke after diagnosis are more likely to develop secondary cancers and have higher rates of cancer- and noncancer-related mortality [73,74]. After surgical resection with curative intent, second tumors are 2.3 times more common and recurrent tumors are 1.9 times more common in patients who continue to smoke. Overall mortality in smokers is 2.9 times higher [70]. Drug metabolism can also be affected by current smoking. Finally, lung cancer patients who quit at the time of initial diagnosis report improved quality of life compared with those patients who continue smoking [70].
Despite the known health risks, smoking is prevalent among survivors of lung cancer. Based on a large population-based survey, 39 percent of lung cancer patients reported smoking at the time of diagnosis, and 14 percent reported smoking at five months postdiagnosis [75].
Unfortunately, long-term cessation is not an easy goal to achieve. Even patients who quit prior to surgery can have high relapse rates. For example, in one study, nearly 40 percent of smokers who quit before surgery relapsed during the postoperative period [76]. Lung cancer patients who are significantly more likely to be persistent smokers include those who have Medicare or other public insurance, are not having chemotherapy, are not having surgery, have prior cardiovascular disease, have lower body mass index (BMI), have less emotional support, and have higher daily smoking rates [75].
As lung cancer patients are diagnosed at earlier, more curable stages, smoking cessation is even more relevant and critical. All health care providers treating lung cancer survivors should adhere to the National Comprehensive Cancer Network guidelines for smoking cessation, including assessment of current tobacco use, advising current smokers to quit, and providing or referring current smokers to evidence-based, pharmacologic, and behavioral tobacco treatment. (See "Overview of smoking cessation management in adults".)
Although clinicians who care for lung cancer patients recognize the importance of tobacco cessation as a necessary part of clinical care, many still do not routinely provide assistance to their patients. A survey of thoracic oncology care providers showed that over 90 percent believe that current smoking affects clinical outcomes and that cessation should be a standard part of clinical care [77]. Although 90 percent of thoracic oncology providers asked patients about tobacco use and 81 percent advised patients to quit, only 40 percent discussed cessation medication options and 39 percent actively provided cessation assistance. Increasing tobacco cessation will require increased assessment and cessation at diagnosis and during follow-up, increased clinician education, and improved tobacco cessation methods. There is strong consensus that greater attention to tobacco dependence and delivery of evidence-based smoking cessation treatment are essential for high-quality cancer care [78].
Diet — There is limited research on the role of diet in the care of lung cancer survivors. There are also relationships between tobacco use and dietary patterns that introduce the potential for significant bias and confounding in these analyses. However, higher rates of fruit and vegetable consumption are consistently associated with reduced risk of lung cancer among both smoking and nonsmoking populations [79].
Weight — Limited evidence suggests higher baseline weight and weight gain during treatment are correlated with improved outcomes in lung cancer. Given that smoking is associated with lower body weight and with poor outcomes in lung cancer, it is not clear whether there are any true relationships between body weight and lung cancer outcomes, but some evidence has suggested that those who are underweight may experience worsened surgical outcomes for resectable NSCLC.
The International Lung Cancer Consortium conducted a retrospective analysis with 25,430 NSCLC patients from 16 studies to evaluate the association between BMI and lung cancer survival outcomes. Those who were underweight with a BMI of <18.5 kg/m2 or morbidly overweight with a BMI of >40 kg/m2 at the time of diagnosis had poorer survival outcomes, across clinical demographics. However, those who were slightly overweight with a BMI of 25 to ≤30 kg/m2 had improved survival outcomes [80].
In a retrospective analysis of over 1500 patients with resected lung cancer, surgical resection-related mortality was 2.9 percent among those who were underweight, 0.6 percent among normal-weight individuals, 1.7 percent among those who were overweight, and 0 percent in persons with obesity [81].
Weight gain during treatment may be a surrogate for clinical outcomes or of smoking cessation, which is often accompanied by weight gain. In an analysis of 92 stage IIIB NSCLC patients treated with definitive split-course chest radiation and concurrent platinum-containing chemotherapy, patients in the highest quartile of weight gain (>4.5 pounds) had an improved three-year survival rate relative to those who did not achieve this level of weight gain (55 versus 31 percent). Weight gain was the only significant predictor of survival in multivariate analysis [82].
Physical activity — Physical activity among lung cancer survivors is low, both shortly after the end of the treatment [83] and years after treatment [84]. A growing number of studies have suggested that preoperative exercise programs may improve surgical outcomes and shorten length of hospital stay after lung resection in lung cancer patients [85], suggesting that lung cancer survivors may benefit from rehabilitation programs and/or encouragement to be more physically active [86,87].
Long-term lung cancer survivors who report more physical activity reported significantly better quality of life in all five measured domains (mental, physical, emotional, social, spiritual), less difficulty with symptom control, and decreased pain severity compared with those who were not physically active [88]. Older individuals and those lung cancer survivors that experienced surgical complications have reported less engagement in walking and other moderately strenuous activities. Evidence shows that exercise is safe and effective at improving physical fitness and muscle strength both before and after treatment for NSCLC survivors [89] and should be encouraged for sedentary lung cancer survivors. Given that many of these patients have cardiac and pulmonary comorbidities, cardiopulmonary rehabilitation may also be helpful before or after surgery. (See "The roles of diet, physical activity, and body weight in cancer survivors", section on 'Physical activity'.)
Financial toxicity/employment implications — Financial worries may add to the stress experienced by patients with lung cancer and their caregivers. Given the demands of treatment, many patients diagnosed and treated for lung cancer will not return to work. Among cancer patients employed at the time of diagnosis, employees with lung cancer had the longest duration of disability absence. In addition, they are two to three times more likely to be unemployed after treatment. Evidence shows that those with low incomes who are from marginalized communities face greater challenges returning to work. [90,91].
Family — Lung cancer and its treatment are challenging for patients and their caregivers. Many caregivers of patients with lung cancer experience negative physical and mental health effects of caregiving, whereas relations with family members improve for a substantial minority of caregivers. Despite reporting improved relations, caregivers and family members have reported challenges coping with the late effects of treatment and establishing a new normal [20,92,93].
These positive and negative consequences of caregiving should be considered when developing post-treatment interventions for this population. Distressed caregivers of lung cancer patients typically underuse mental health services, yet a sizable minority are interested in receiving professional assistance with psychosocial and practical needs [94].
COORDINATION OF CARE — The care of lung cancer survivors requires coordination among various providers, which include oncology specialists (surgeon, medical oncologist, and/or radiation oncologist) and primary care specialists. Access to mental health clinicians with expertise in the psychosocial support of cancer survivors is also likely to promote adaptation to the challenges associated with lung cancer survivorship. Lung cancer survivors are likely to have comorbid chronic medical conditions, largely attributable to their older age and the high prevalence of smoking history in this group. The most common comorbid conditions are cardiovascular and pulmonary diseases, and survivors with comorbid pulmonary disease are likely to report a sedentary lifestyle and impairment in post-treatment quality of life [9,21,95].
The care of the lung cancer survivor must take into account multiple concerns. Management of treatment-related symptoms, side effects, and sequelae from surgery, radiation therapy, and/or chemotherapy are generally best handled by the treating clinician. However, lung cancer survivors are often older and many have chronic comorbid conditions. These may be more suitably managed by their primary care providers (PCPs), who may have long-standing relationships with their patients. Cancer surveillance can be conducted by either the PCP or the treating cancer specialist, as long as one adheres to the recommended regimens and timely consultations are sought if suspicious findings develop.
The coordination of care between those responsible for the original lung cancer treatment and the PCP, therefore, is of the utmost importance. While the surgeon, radiation oncologist, or medical oncologist may be particularly attuned to the issues of treatment and cancer surveillance, they may not be capable of providing sufficient attention to health behavior modification or chronic symptom management. On the other hand, the PCP may provide better preventative care but not be familiar with the management of lung cancer and the sequelae of cancer therapy. (See "Overview of cancer survivorship care for primary care and oncology providers".)
Nurse practitioner model — Some have advocated bridging the divide between oncology providers and PCPs with dedicated nurses or nurse practitioners (NPs). A randomized trial of nurse-led follow-up of lung cancer patients versus conventional medical follow-up found that nurse-led follow-up was feasible and reported higher patient satisfaction with the nurse care model. Patient acceptability of nurse-led follow-up was high (75 percent), and there were no differences in survival or disease progression in the two groups [96].
Similar acceptance was found among 655 patients in an NP-led survivorship program at a large cancer center, where 92 percent of patients in the program elected to remain in the care of the NP rather than return to their thoracic surgeon [97]. An important feature of this model is the close coordination between the survivorship NP and the thoracic surgeon. The importance of surgeon input in the interpretation of surveillance imaging was highlighted in one study demonstrating an accuracy rate of 88 percent when scans reported as abnormal by the radiologist were evaluated by the surgeon [98]. This NP-based model has been shown to have high satisfaction as well as being cost-effective in other cancer populations, such as breast cancer [99].
Indicating need for greater continuing education, a survey examined awareness of long-term effects of chemotherapy across 1130 oncologists and 1072 PCPs and found that only 6 percent of PCPs were aware of the major long-term effects of four common chemotherapy agents compared with 65 percent of oncologists [100].
Regardless of the follow-up model used, close attention to treatment-related symptoms, chronic comorbidities, and cancer surveillance for both recurrence and the development of second malignancies must be paid to provide optimal care for the lung cancer survivor.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Diagnosis and management of lung cancer".)
SUMMARY AND RECOMMENDATIONS
●Lung cancer survivors are at risk for recurrence of their original cancer, for the development of second primary lung cancers, and for the development of other cancers, particularly those related to smoking. Thus, close surveillance is required for survivors in an effort to detect such malignancies at an early stage. (See 'Surveillance after treatment' above.)
•A history, physical examination, and chest computed tomography (CT) including the adrenals, preferably with intravenous contrast, are indicated every six months for at least the first two years to evaluate for recurrence, and annually thereafter to surveil for recurrence and for new cancers. Continued follow-up beyond five years with low-dose CT screening is reasonable in patients who have no evidence of disease, since these individuals are at risk for a second primary lung cancer as well as for recurrence. (See 'Approach' above.)
●Lung cancer survivors commonly report post-treatment symptoms such as pain, dyspnea, distressed mood, sleep impairment, and fatigue even after their initial treatment, which negatively impact quality of life. In addition, lung cancer survivors are likely to have comorbid chronic medical conditions. (See 'Symptoms' above.)
●Smoking cessation is indicated both to decrease the risk of a second primary malignancy and to reduce comorbidity. Patients should receive cessation counseling, advice, and pharmacotherapy. (See 'Persistent tobacco use' above and "Overview of smoking cessation management in adults".)
●The coordination of care between those providing the original lung cancer treatment and the primary care provider (PCP) is of the utmost importance. Management of treatment-related symptoms, side effects, and sequelae from surgery, radiation therapy, and/or chemotherapy is generally handled by the treating clinician. However, chronic comorbid conditions may be more suitably managed by PCPs who have long-standing relationships with their patients. (See 'Coordination of care' above.)
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